UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES

MEDICAL CENTER

 

PROCEDURE

PROCEDURE:

111

EFFECTIVE:

1/82

REVISION:

3/05

APPROVAL:

3/05

PROCEDURE FOR THE CARE AND MAINTENANCE  OF PERIPHERALLY INSERTED CENTRAL CATHETERS (PICCs)  IN ADULTS AND ADOLESCENTS

PURPOSE: To prevent infection, maintain patency, and ensure catheter integrity.

SUPPORTIVE DATA:

PICCs are made of a silastic or polymer material, and are inserted into the peripheral venous system, usually into a vein near the antecubital fossa. They come in a variety of sizes, may have single or double lumens, and can provide short or long term IV access. PICCs are placed, repaired, and discontinued by PICC trained person. When educating patients who will be discharged with the line, it is requested that another caregiver also learn to care for the PICC.

EQUIPMENT:

DRESSING/SECUREMENT DEVICE/INJECTION CAP OR NEEDLELESS VALVE SYSTEM

Subclavian/TPN dressing kit
Securement Device
Needleless valve system

2 alcohol pads

 

FLUSHING

Heparin Flush (100units/ml)
Normal saline for flush, if indicated
5ml or greater syringe
Alcohol and/or 2% chlorhexidine sepp

PROCEDURE STEPS:

*USING UNIVERSAL PRECAUTIONS*

Dressing/Securement Device/needleless valve change:

  1. Position the patient with the arm extended. Wash hands. 
  2. Rub an alcohol pad over the dressing where it meets the securement device plastic doors.  This eases the removal of the dressing over the securement device.

KEYPOINT: DO NOT use scissors to remove old dressing.

  1. Carefully remove old dressing from over the securement device first -- pulling towards the insertion site and using the stretch technique.   After uncovering the securement device, leave the old dressing over the insertion site to stabilize the catheter while removing the securement device from the patient’s arm.
  2. Gently lift plastic doors of the securement device one at a time.  Carefully remove PICC line from retainer. 
  3. Apply a generous amount of alcohol to loosen edge of pad.  Gently stroke undersurface of pad with alcohol to dissolve the adhesive as pad slowly lifts away from the skin.  Do not pull or force pad for removal.  Remove the rest of the old dressing.

 KEYPOINT:  The securement device kit contains a foam stabilizer for use on the catheter during the dressing change if more support for stabilization is needed. 

  1. Instruct the patient not to move the arm while site is exposed. Discard old dressing and securement device  and re-wash hands.
  2. Assess catheter insertion site for possible dislodgement.  Notify MD or CVL Coordinator if catheter appears to be dislodged after dressing change is completed.
  3. Assess the insertion site and surrounding area for sign or symptoms of infection. Note integrity of catheter.
  4. Open the kit, touching only the corners of the sterile overwrap.
  5. Open new securement device kit, touching only the corners of the sterile overwrap.
  6. Put on sterile gloves and open all packages in kits, placing upright in tray.
  7. If dry bloody residue present, clean with the alcohol/acetone swab. Allow to dry.
  8. Clean in an alternating horizontal and vertical motion with the 2% chlorhexidine sponge for 30 seconds.  It is not necessary to clean in a circular motion. Allow to dry.

KEYPOINT:  Do not use alcohol at the insertion site after chlorhexidine is applied.  Alcohol will remove the chlorhexidine barrier left on the skin.

  1. Prep the skin ONLY where the securement device will be applied by using the skin prep in the securement device kit.  Allow to dry completely.
  2. Using the securement device: first, place suture hole of one side of catheter wing over post, then slide post and wing toward opposite side until second suture hole fits over second post.  Close doors of plastic cradle to secure catheter.
  3. Apply the securement device to skin by peeling away paper backing and placing onto skin.

        KEYPOINT:  Never apply securement device to skin before securing catheter to it. 

  1. Place the transparent bio-occulsive dressing over the catheter and the securement device, centering over the insertion site. Remove sterile gloves.

KEYPOINT: A transparent, bio-occulsive dressing is preferred for the PICC. The dressing and securement device should be changed weekly and/or PRN. It is important that the dressing remain occlusive and the StatLock adheres and is not soiled. PICCs MUST be secured with a securement device as they are not sutured.

  1. Label dressing with date and initials.

  2. Change needleless valve system weekly and/or PRN.

FLUSHING STANDARDS:

  1. Clean the needleless valve system vigorously for 15 seconds with alcohol and/or 2% chlorhexidine for 30 seconds and allow to dry completely.

KEYPOINT: Use only a 5ml or greater syringe. Smaller syringes can increase pressure and potentially rupture the catheter. Treat each lumen separately for maintenance and flushing. PICCs must be flushed very punctually at the end of gravity infusions to avoid potential catheter embolus.

2.        Gently flush using 3ml normal saline in a 5ml or greater syringe.

3.        Re-clean injection cap/needleless valve system with alcohol and/or 2% chlorhexidine and allow to dry.

4.        Gently flush using 1 ml (100units/ml) heparin in a 5ml or greater syringe every 24 hours and/or after each intermittent use.

KEYPOINT: When infusion is complete, flush PICC promptly to avoid embolus. When using needle free system always flush, clamp catheter, then remove syringe.

DRAWING BLOOD SPECIMENS:

  1. Turn off all infusing solution prior to sampling.
  2. Position patient with PICC arm 90 degree angle to midline.
  3. Clean needleless valve system vigorously for 15 seconds with alcohol and/or 2% chlorhexidine for 30 seconds and allow to dry completely.
  4. Flush line with 5-10ml of normal saline using a 5ml or greater syringe.  Leave that syringe attached and wait approximately 2 minutes.
  5. Withdraw 3-5ml of blood with the attached syringe and discard.
  6. Withdraw amount of blood needed for specimen.
  7. Flush with 5-10ml normal saline and resume infusion or heparinize as indicated.

KEYPOINT: PICC’s 3.0 Fr. or smaller may not provide consistent blood return.

 

REFERENCES:
Camp-Sorrell, D. (2004). Access Device Guidelines, 2nd Edition.  Oncology Nursing Society.  Pittsburgh. P.6.

Infusion Nursing Standards of Practice, (2000).  Journal of Intravenous Nursing.   23(6S):  pp 53-54.

O’Grady NP, Alexander MBS, Dellinger E, et.al. (2002).  Guidelines for the Prevention of Intravascular Catheter-Related Infections (Centers for Disease Control).  American Journal of Infection Control.  2002; 30(8): 476-489.

 

Venetec International:  Product information for use of StatLock PICC Plus.  www.statlock.com

RESOURCE PERSON(S):   Mark S. Rowe, RNP, MNSc; Naomi M. Crume, RNP, BSN; Donna Elrod, RN, MSN, AOCN